AB0404 DE-ESCALATION OF ANTI-TNFS IN OLDER ADULTS WITH RHEUMATOID ARTHRITIS
Authors: J. Lee, N. Singh, R. Yung, U. Makris, J. Bynum
Journal: Annals of the Rheumatic Diseases (2023)

<h3>Background</h3> Biologic disease modifying anti-rheumatic drugs (bDMARDs) such as anti-TNFs improve clinical and radiographic outcomes in rheumatoid arthritis (RA). However, their use is associated with dose- and age-dependent adverse effects including increased risk of serious infections. In recent years, de-escalation (or deprescribing) has been proposed as an approach to reduce polypharmacy and optimize medication use in older adults more prone to the negative, often additive, adverse effects of medications. Current clinical practice guidelines recommend de-escalating bDMARDs in RA patients with low disease activity or in remission. Whether and how bDMARDs are de-escalated in usual care in older adults with RA is poorly understood. <h3>Objectives</h3> To evaluate prevalence and factors associated with anti-TNF de-escalation in older adults with RA. <h3>Methods</h3> In this retrospective observational study using 20% Medicare data from 2009-2017, we identified adults 66 years of age or older with RA, on anti-TNF therapy within 6 months of cohort entry date with at least 6-7 months duration (proxy for stable use). We evaluated the use of five anti-TNFs: Adalimumab, Etanercept, Certolizumab, Golimumab, and Infliximab. Baseline patient characteristics including comorbidity and concomitant use of glucocorticoid (GC) and other DMARDs were collected. Anti-TNF use was categorized as either continuation or de-escalation, identified by dose reduction, dosing interval increase or cessation of use. <h3>Results</h3> We identified 5720 Medicare beneficiaries who met study inclusion criteria. Average age was 74.0 (SD 5.8), 77.9% were female, 83.3% were non-Hispanic white, 26.4% had low-income subsidy, and average Elixhauser comorbidity count was 2.2 (SD 2.0). At baseline, 65.7% had concomitant conventional synthetic DMARD (csDMARD) use and 30.9% were on long-term (≥90 days) GCs. During the study period, one in five de-escalated anti-TNFs (20.1%), of whom 61.3% either reduced dose or increased dosing interval and 38.7% ceased use. Compared to those with continuation of use, de-escalators had more concomitant csDMARD use (60.0% versus 56.5%) and less long-term GC use (26.6% vs 30.9%). In multivariable analyses, de-escalation was less likely in those with low-income subsidy (HR 0.70, 95% CI 0.60-0.82, p&lt;0.0001), adjusting for patient age, sex, race/ethnicity, and comorbidity as a time-varying variable (Table 1). <h3>Conclusion</h3> Anti-TNFs are de-escalated in one in five older adults with RA in usual care. Further study is needed to evaluate impact of de-escalation on RA outcomes. <h3>References</h3> [1]Vela P, Sanchez-Piedra C, Perez-Garcia C, Castro-Villegas MC, Freire M, Mateo L, Díaz-Torné C, Bohorquez C, Blanco-Madrigal JM, Ros-Vilamajo I <i>et al</i>: Influence of age on the occurrence of adverse events in rheumatic patients at the onset of biological treatment: data from the BIOBADASER III register. <i>Arthritis research &amp; therapy</i> 2020, 22(1):143. [2]Navarro-Millán I, Sattui SE, Curtis JR: Systematic review of tumor necrosis factor inhibitor discontinuation studies in rheumatoid arthritis. <i>Clinical therapeutics</i> 2013, 35(11):1850-1861.e1851. [3]Schett G, Emery P, Tanaka Y, Burmester G, Pisetsky DS, Naredo E, Fautrel B, van Vollenhoven R: Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions. <i>Ann Rheum Dis</i> 2016, 75(8):1428-1437. <h3>Acknowledgements:</h3> NIL. <h3>Disclosure of Interests</h3> None Declared.